Brief communication: Chest radiography score in young COVID-19 patients: Does one size fit all?

Gioele Castelli; Umberto Semenzato; Sara Lococo; Elisabetta Cocconcelli; Nicol Bernardinello; Giulia Fichera; Chiara Giraudo; Paolo Spagnolo; Annamaria Cattelan; Elisabetta Balestro

doi:10.1371/journal.pone.0264172

Peer Review History

Original SubmissionMarch 9, 2021
14 Jul 2021 Decision Letter - Eman Sobh, Editor PONE-D-21-07724 Brief communication: chest radiography score in young COVID-19 patients: does one size fit all? PLOS ONE Dear Dr. Balestro, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Aug 12 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Eman Sobh, M.D. Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. Please amend your Methods section to state the full name of your institutional ethics board and please provide the same information stated in your Ethics Statement regarding the waiver of consent. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: No Reviewer #2: Partly Reviewer #3: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: No Reviewer #2: Yes Reviewer #3: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: No Reviewer #2: Yes Reviewer #3: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The study design as mentioned lack the good number of Patients but the most important clinical error it lacks standardization as we know CXR to reveal opacities and lung shadows specially consolidation and GGO in cases of COVID 19 it should be standard. Exposure is one factor, type of CXR PA versus AP will affect the reading of CXR , we know also the different radiologists may read Same CXR differently and inter observer variability if a factor that limit CXR scoring , these points were not clearly delineated in the study There is overlap between different causes of GGO and consolidations even in COVID as pulmonary edema and pleural effusion that might be misinterpreted in CXR as consolidation, it was not clearly identified in the study Reviewer #2: The manuscript must be checked by any grammar program. Abstract • Amend “patients’ prognosis” To “patients’ prognoses” • Amend “In our study” To “In our study,” Introduction The introduction was too short and I think it will be better to conclude more studies about CXR scores and its prognostic value. • Amend “Aim of our study was to assess the value of this” To “Our study aimed to assess the value of this” Materials and Methods 1. Description of the methodology was concise and contained summarized description of well-established selection parameters. 2. The number of patients was suitable (51 patients) but it could be statistically accepted. 3. The choice of young and middle age was interesting. 4. Inclusion and Exclusion criteria seem logical. 5. Amend “CXR was divided in” To “CXR was divided into” 6. Amend “score equal or major to 3 as cut-off to categorize” To “score equal or major to 3 as a cut-off to categorize” 7. Amend “Clinical outcomes assessed in our cohort were: need for high-intensity” To “Clinical outcomes assessed in our cohort were: the need for high-intensity” Results and Discussion 1. The results were represented by nice and informative radiographic images. 2. The study findings were adequately discussed. Research criteria (1 = Excellent) (2 = Good) (3 = Fair) (4 = poor) Originality 3 Contribution to the field 3 Technical quality 3 Clarity of Presentation 2 Depth of Research 3 Decision The study is interesting. Therefore, I recommend it for publication after minor corrections. Reviewer #3: The present brief communication provides interesting data on role chest radiography score in young COVID-19 patients. The study is well presented and proper analysed. Just a few suggestions: 1) it is known from literature that higher d-dimer level is significantly associated with a worse prognosis even in young and middle aged patients (i-e. Bonifazi et al Journal of Clinical Medicine 2021). It would be interesting, if available, to include baseline values in the multivariate analysis. If not available, i suggest to mention the lack of infomation on clinical features likely to influence outcomes, as limitation. 2) Were baseline CTs available for study population? if yes, il would be interesting to correlate CT scores with Rx scores 3) Among study limitations i would mention also the retrospective nature of the study ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: Yes: Prof Hassan Mohamed Ahmed Aref Shabana Reviewer #2: Yes:** Amr A. Abd-Elghany Reviewer #3: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0264172.r001
Revision 1
2 Aug 2021 Author Response Journal Requirements: 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The manuscript has been amended as requested. 2. Please amend your Methods section to state the full name of your institutional ethics board and please provide the same information stated in your Ethics Statement regarding the waiver of consent. The full name of the institutional ethics board and the waiver of consent has been added (page 3 lines 43-45) Reviewers' comments: Reviewer #1, comment 1: The study design as mentioned lack the good number of Patients but the most important clinical error it lacks standardization as we know CXR to reveal opacities and lung shadows specially consolidation and GGO in cases of COVID 19 it should be standard. Response to reviewer #1, comment 1: As stated also by the reviewer we mentioned that sample size is a limitation of our contribution. However, it is important to underline that all subjects were fully characterized, and consecutively collected in order to reduce selection bias. Moreover, regarding CXR standardization it’s crucial to mention the peculiar health system organization from the beginning of pandemic with a single Radiology Unit dedicated to COVID-19 patients from the Emergency Department, with the same CXR equipment, staff and setting. This point is now better clarified in the Material and Methods section (page 3, lines 49-51). Furthermore, multiple CXR scores have already been standardized as prognostic tools both in COVID-19 and ARDS, as we now included in the introduction (page 3, lines 34-38). Reviewer #1, comment 2: Exposure is one factor, type of CXR PA versus AP will affect the reading of CXR , we know also the different radiologists may read Same CXR differently and inter observer variability if a factor that limit CXR scoring , these points were not clearly delineated in the study Response to reviewer #1, comment 2: we agree with reviewer’s comment and according to Toussie’s score method, which we aimed to validate in a different cohort, patients were included if underwent either digital anteroposterior chest radiography (47 of 51, 92%) or digital posteroanterior and lateral chest radiography (4 of 51, 8%). This point is now better explained in the Materials and Methods section (page3, lines 48, 49) and Results section. Interobserver variability was a major concern, thus readers were trained for applying Toussie’s CXR score, obtaining a moderate to substantial interobserver concordance among two different readers (Cohen's kappa coefficient (κ) ranging from 0.55 to 0.66 in different lobes). Reviewer #1, comment 3: There is overlap between different causes of GGO and consolidations even in COVID as pulmonary edema and pleural effusion that might be misinterpreted in CXR as consolidation, it was not clearly identified in the study. Response to reviewer #1, comment 3: We agree with the reviewer, CXR interpretation can be confounded by comorbid conditions, like heart failure or chronic lung disease. However, considering that our patients were under 50 years old, the incidence of comorbidities that could lead to CXR misinterpretation within this age was very low (3 of 51, 6%). Reviewer #2: The manuscript must be checked by any grammar program. Abstract • Amend “patients’ prognosis” To “patients’ prognoses” • Amend “In our study” To “In our study,” Introduction The introduction was too short and I think it will be better to conclude more studies about CXR scores and its prognostic value. • Amend “Aim of our study was to assess the value of this” To “Our study aimed to assess the value of this” Materials and Methods 1. Description of the methodology was concise and contained summarized description of well-established selection parameters. 2. The number of patients was suitable (51 patients) but it could be statistically accepted. 3. The choice of young and middle age was interesting. 4. Inclusion and Exclusion criteria seem logical. 5. Amend “CXR was divided in” To “CXR was divided into” 6. Amend “score equal or major to 3 as cut-off to categorize” To “score equal or major to 3 as a cut-off to categorize” 7. Amend “Clinical outcomes assessed in our cohort were: need for high-intensity” To “Clinical outcomes assessed in our cohort were: the need for high-intensity” Results and Discussion 1. The results were represented by nice and informative radiographic images. 2. The study findings were adequately discussed. Research criteria (1 = Excellent) (2 = Good) (3 = Fair) (4 = poor) Originality 3 Contribution to the field 3 Technical quality 3 Clarity of Presentation 2 Depth of Research 3 Decision The study is interesting. Therefore, I recommend it for publication after minor corrections. Response to reviewer #2. We would like to thank the reviewer for all the comments. We amended the manuscript accordingly to your suggestions as you can see in the revised version. Moreover, in the introduction, we now mentioned a larger number of studies on CXR scores and their prognostic value (page 3 lines 34-38). We are glad that the reviewer had considered our results well discussed and our methodology suitable for this study. We are aware of the small sample size (as we stated in study limitations), however the limited number was also due to the consecutive enrollment we on purpose applied to reduce selection bias. Reviewer #3: The present brief communication provides interesting data on role chest radiography score in young COVID-19 patients. The study is well presented and proper analysed. Just a few suggestions: 1) it is known from literature that higher d-dimer level is significantly associated with a worse prognosis even in young and middle aged patients (i-e. Bonifazi et al Journal of Clinical Medicine 2021). It would be interesting, if available, to include baseline values in the multivariate analysis. If not available, i suggest to mention the lack of infomation on clinical features likely to influence outcomes, as limitation. 2) Were baseline CTs available for study population? if yes, il would be interesting to correlate CT scores with Rx scores 3) Among study limitations i would mention also the retrospective nature of the study Response to reviewer #3. We thank the reviewer for comments and suggestions that improved our manuscript. 1) The cited article is very interesting and supports our results on the importance of the BMI in young COVID-19 patients, we did not quoted it before because it was not published at the time of our submission; now it is mentioned in page 6 lines 94-96. We then repeated the multivariate analysis including baseline D-dimer level, that was available in our subjects. The new analysis confirmed that high radiological risk score, diabetes and the need of high-intensity medical setting were independent risk factors for prolonged hospitalization also including baseline D-dimer, that was not a risk factor itself (OR 0.998. CI 95%: 0.990-1.005; p=0.556). 2) Unfortunately baseline CTs in this cohort were not available, because in our hospital during the first wave, CT scans were not largely and easily available for all patients, as it would have been later in the second wave. 3) Thank you for the suggestion, we included the suggested limitation in the discussion (page 7, line 103). Attachments Attachment Submitted filename: Response to reviewer PLOS ONE.doc https://doi.org/10.1371/journal.pone.0264172.r002
20 Oct 2021 Decision Letter - Eman Sobh, Editor PONE-D-21-07724R1Brief communication: chest radiography score in young COVID-19 patients: does one size fit all?PLOS ONE Dear Dr. Balestro, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. ============================== ============================== Please submit your revised manuscript by Dec 04 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Eman Sobh, M.D. Academic Editor PLOS ONE [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: (No Response) Reviewer #3: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: No Reviewer #3: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: No Reviewer #3: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #3: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #3: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: I apologize for being in the second revision for the manuscript after it was reviewed before but I have comments As stated by the authors the number enrolled in the study is statistically low to generate a conclusion that can be accepted for practical use , I would recommend a multi centre collection of cases specially it is a retrospective study and can easily get higher number than selected Also some other important points should be highlighted 1- From symptom onset to CXR is seen shorter in mild group compared to severe group despite that it is not statistically significant but as we know covid pneumonia is a progressive disease and if the patient is presenting late , his CXR might show more shadows, which might reflect late presentation in the severe group , so I can not judge that patients with mild CXR shadows are expected to have milder form of the disease, as it will progress in the few coming days , it was not stated in the methods patients who might come twice to the hospital with worsening symptoms and condition are excluded or not, if not which CXR was selected 2- As many cases of covid pneumonia are are afebrile throughout their illness , I feel fever in the table is of no value , and as oxygen saturation and respiratory rate are important vital signs in assessment of respiratory affection in covid pneumonia and it is easily assessed in all hospitals at presentation, I would recommend adding these parameters in the table beside or instead of fever 3- it was not mentioned in the methods who assessed the CXR shadows, and if they were aware about the patient clinical status and if there is any bias in their interpretation of CXR reading , is there any interobserver variability Thanks Reviewer #3: I think this is a good work. the authors have properly answered to all my questions, I have no further comments ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: Yes:** Dr Hassan Aref Shabana Reviewer #3: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0264172.r003
Revision 2
27 Oct 2021 Author Response Reviewer #1, comment: As stated by the authors the number enrolled in the study is statistically low to generate a conclusion that can be accepted for practical use , I would recommend a multi centre collection of cases specially it is a retrospective study and can easily get higher number than selected Response to reviewer #1, comment: in full agreement with the reviewer, we’ve already emphasized that small sample size is a limitation of our contribution. However, it is important to underline that all subjects were fully characterized, and consecutively collected in order to reduce selection bias. Of note, we’ve chosen not to extend the study population to the so called “second and third pandemic wave” because several treatments have been put in place (i.e. steroid treatment) which could have influenced the outcome. Indeed we believe that “first pandemic wave” represents a unique population which is difficult to merge with the subsequent pandemics. We agree with the reviewer that multicentric studies could lead to more significant results, however this topic will be addressed together with other centers in future studies. We added the monocentricity of this study to our limitations in the Discussion section (page 7, line 114-115). Reviewer #1, comment 1: From symptom onset to CXR is seen shorter in mild group compared to severe group despite that it is not statistically significant but as we know covid pneumonia is a progressive disease and if the patient is presenting late , his CXR might show more shadows, which might reflect late presentation in the severe group , so I can not judge that patients with mild CXR shadows are expected to have milder form of the disease, as it will progress in the few coming days , it was not stated in the methods patients who might come twice to the hospital with worsening symptoms and condition are excluded or not, if not which CXR was selected Response to reviewer #1, comment 1: We agree with the reviewer on this point, actually even if there was no statistical difference in the two groups, we searched for multiple access to the ER. Of note, all patients have been hospitalized after the first ER admission. Following the reviewer’s comment we clarified this point in the Materials and Methods (page 4 lines 51-52) and Results sections (page 4 lines 69-70). Reviewer #1, comment 2: As many cases of covid pneumonia are are afebrile throughout their illness , I feel fever in the table is of no value , and as oxygen saturation and respiratory rate are important vital signs in assessment of respiratory affection in covid pneumonia and it is easily assessed in all hospitals at presentation, I would recommend adding these parameters in the table beside or instead of fever Response to reviewer #1, comment 2: We apologize, but the aim of our study was to replicate Toussie’s study on Radiology, so we kept the same parameters in our evaluation. We agree with the reviewer to add an evaluation of the gas exchanges, we used the P/F ratio, avoiding the bias of peripheral oxygen saturation due to oxygen supplementation. Confirming previous literature, P/F ratio was significantly lower (p=0.03) in HRRS patients. We then included this result in Table 1, in Results (page 6 lines 89-91) and Discussion section (page 7 lines 103-104). Unfortunately, respiratory rate was not routinely mentioned in medical records, and over 40% of the patients presented only semantic formulas like eupneic or tachipneic. Due to this lack of data we preferred not to include this parameter in our study. Reviewer #1, comment 3: it was not mentioned in the methods who assessed the CXR shadows, and if they were aware about the patient clinical status and if there is any bias in their interpretation of CXR reading , is there any interobserver variability Response to reviewer #1, comment 3: We thank the reviewer for this comment which is helpful to improve our contribution.; we therefore amended Materials and Methods (page 4 lines 54-56 and lines 60-61) and Results section (page 4 lines 71-73) including the required information. Reviewer #3: I think this is a good work. the authors have properly answered to all my questions, I have no further comments Response to reviewer #3: We thank the reviewer for the kind comment. Attachments Attachment Submitted filename: Response to reviewer n. 2 PLOS ONE.doc https://doi.org/10.1371/journal.pone.0264172.r004
7 Feb 2022 Decision Letter - Eman Sobh, Editor Brief communication: chest radiography score in young COVID-19 patients: does one size fit all? PONE-D-21-07724R2 Dear Dr. Balestro, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Eman Sobh, M.D. Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed Reviewer #3: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #3: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #3: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #3: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #3: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: (No Response) Reviewer #3: (No Response) ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #3: No https://doi.org/10.1371/journal.pone.0264172.r005
Formally Accepted
14 Feb 2022 Acceptance Letter - Eman Sobh, Editor PONE-D-21-07724R2 Brief communication: chest radiography score in young COVID-19 patients: does one size fit all? Dear Dr. Balestro: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Eman Sobh Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0264172.r006

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